Sedation Management in the Intubated Pediatric Patient as a Method to Reduce Neuromuscular Blockade Utilization Rate During Transport: A Quality Improvement Project.

Objective: Models recommending continuous sedation combined with specific tools to assess sedation depth during pediatric transport do not exist. Published studies demonstrate that nurse-driven sedation protocols yield more consistent levels of appropriate sedation.

Methods: A retrospective review in 2020 of mechanically ventilated pediatric transport patients at this institution demonstrated that 60.

Improving Accuracy of Medication Reconciliation for Hospitalized Children: A Quality Project.

Background And Objectives: Medication reconciliation is a complex, but necessary, process to prevent patient harm from medication discrepancies. Locally, the steps of medication reconciliation are completed consistently; however, medication errors still occur, which suggest process inaccuracies. We focused on removal of unnecessary medications as a proxy for accuracy.

3D assessment of graft malposition after ACL reconstruction: Comparison of native and 11o'clock ligament orientations.

Background: Femoral tunnel malposition makes up the majority of technical failures for ACL reconstructive surgery. The goal of this study was to develop adolescent knee models that accurately predict anterior tibial translation when undergoing a Lachman and pivot shift test with the ACL in the 11o'clock femoral malposition (Level of Evidence: IV).

Methods: FEBio was used to build 22 subject-specific tibiofemoral joint finite element representations.

Comparison of side-cutting maneuvers versus low impact baseball swing on knee ligament loading in adolescent populations.

Background: High impact sports are associated with an increased incidence rate for knee ligament injuries, specifically pertaining to the anterior cruciate ligament and medial collateral ligament. What is less clear is (i) the extent to which high impact activities preferentially load the anterior cruciate ligament versus the medial collateral ligament, and (ii) whether both ligaments experience similar stretch ratios during high loading scenarios. Therefore, the goal of this project was to assess how different loading conditions experienced through more at-risk sporting maneuvers influence the relative displacements of the anterior cruciate ligament and medial collateral ligament.

Pivot shift and Lachman test simulation-based exploration in juvenile populations for accurately predicting anterior tibial translation.

Advancements in technology and finite element software have made it possible to develop simulation-based exploration of subject-specific tibiofemoral joint kinematics. In this study, the goal was to develop baseline knee models that accurately predict anterior tibial displacement when undergoing a Lachman and pivot shift test. A total of 22 subject-specific adolescent tibiofemoral joint finite element representations were developed using FEBio.

Opioid Reduction Through Postoperative Pain Management in Pediatric Orthopedic Surgery.

Objectives: Our goal with this initiative was to reduce discharge opioid prescriptions while maintaining optimal pain management through the use of standardized pain prescribing guidelines for pediatric patients after orthopedic surgical procedures.

Methods: Through analysis of established yet inconsistent prescribing practices, we created a 4-tiered guideline for pediatric orthopedic postoperative pain management prescription ordering. Following the Model for Improvement methodology including iterative plan-do-study-act cycles, the team created an electronic medical record order set to be used at discharge from the hospital.

Tibial tuberosity anteriomedialization vs. medial patellofemoral ligament reconstruction for treatment of patellar instability related to malalignment: Computational simulation.

Background: Medial patellofemoral ligament reconstruction and tibial tuberosity anteromedialization are common treatment options for recurrent lateral patellar instability, although ligament reconstruction is not commonly applied to knees with lateral malalignment.

Methods: Multibody dynamic simulation was used to assess knee function following tibial tuberosity anteromedialization and medial patellofemoral ligament reconstruction for knees with lateral malalignment. Dual limb squatting was simulated with six models representing knees being treated for patellar instability with an elevated tibial tuberosity to trochlear groove distance.

Lateral patellar maltracking due to trochlear dysplasia: A computational study.

Background: The study focuses on the influence of trochlear dysplasia on patellar tracking related to patellar instability.

Methods: Knee extension against gravity and dual-limb squatting were simulated with seven models representing knees being treated for recurrent instability. Trochlear depth was altered to represent lateral trochlear inclination (LTI) values of 6°, 12° and 24°.

Perioperative Safety: Keeping Our Children Safe in the Operating Room.

The entire operating room team is responsible for the safety of children in the operating room. As a leader in the operating room, the surgeon is impactful in ensuring that all team members are committed to providing this safe environment. This is achieved by the use of perioperative huddles or briefings, the use of appropriate surgical checklists, operating room standardization, surgeons proficient in the care they provide, and team members that embrace Just Culture.

Computational simulation of medial versus anteromedial tibial tuberosity transfer for patellar instability.

The study utilizes dynamic simulation of knee function to determine how tibial tuberosity medialization and anteromedialization influence patellar tracking and contact pressures for knees with patellar instability. Dual limb squatting was simulated with six multibody dynamic simulation models representing knees being treated for patellar instability. Each knee exhibited lateral patellar maltracking in the pre-operative condition based on the bisect offset index.

Dynamic tracking influenced by anatomy following medial patellofemoral ligament reconstruction: Computational simulation.

Background: Continued patellar instability can occur following medial patellofemoral ligament (MPFL) reconstruction. Computational simulation of function was used to investigate the influence of the lateral position of the tibial tuberosity, trochlear dysplasia and patella alta on lateral patellar tracking following MPFL reconstruction.

Methods: Multibody dynamic simulation models were developed to represent nine knees being treated for recurrent patellar instability.

Allowing one quadrant of patellar lateral translation during medial patellofemoral ligament reconstruction successfully limits maltracking without overconstraining the patella.

Purpose: Graft tensioning during medial patellofemoral ligament (MPFL) reconstruction typically allows for lateral patellar translation within the trochlear groove. Computational simulation was performed to relate the allowed patellar translation to patellofemoral kinematics and contact pressures.

Methods: Multibody dynamic simulation models were developed to represent nine knees with patellar instability.

Variations in Tibial Tuberosity to Trochlear Groove and Posterior Cruciate Ligament Distances due to Tibial External and Valgus Rotations.

Tibial rotations with respect to the femur influence measurements used to assess the lateral position of the tibial tuberosity. This study utilized computational modeling to quantify how the tibial tuberosity to trochlear groove (TT-TG) and tibial tuberosity to posterior cruciate ligament attachment (TT-PCL) distances vary with tibial internal/external and varus/valgus rotations. Computational models were developed from magnetic resonance imaging data to represent eight knees with patellar instability.

Role of Computed Tomography in the Classification of Pediatric Pelvic Fractures-Revisited.

Objectives: To determine the need for computerized tomography (CT) scans in the assessment of pediatric pelvic fractures.

Design: Retrospective Chart Review.

Setting: Level-1 Pediatric Trauma Center.

Pediatric Orthopaedic Workforce in 2014: Current Workforce and Projections for the Future.

Background: The changing nature of the United States (US) health care system has prompted debate concerning the physician supply. The basic questions are: do we have an adequate number of surgeons to meet current demands and are we training the correct number of surgeons to meet future demands? The purpose of this analysis was to characterize the current pediatric orthopaedic workforce in terms of supply and demand, both present and future.

Methods: Databases were searched (POSNA, SF Match, KID, MGMA) to determine the current pediatric orthopaedic workforce and workforce distribution, as well as pediatric orthopaedic demand.

The impact of a daily pre-operative surgical huddle on interruptions, delays, and surgeon satisfaction in an orthopedic operating room: a prospective study.

Background: The goal of this project was to implement a daily pre-operative huddle (briefing) for orthopedic cases and evaluate the impact of the daily huddle on surgeons' perceptions of interruptions and operative delays.

Methods: Baseline measurements on interruptions, delays, and questions were obtained. Then the daily pre-operative huddle was introduced.

Gene expression differences between ruptured anterior cruciate ligaments in young male and female subjects.

Background: The incidence of anterior cruciate ligament (ACL) injuries is two to eightfold greater in female compared with male athletes. Anatomic, hormonal, and neuromuscular factors have been associated with this disparity. This study compared gene expression and structural features in ruptured but otherwise normal ACL tissue from young female and male athletes.

Anatomical factors influencing patellar tracking in the unstable patellofemoral joint.

Purpose: The current study was performed to relate anatomical parameters to in vivo patellar tracking for pediatric patients with recurrent patellar instability.

Methods: Seven pediatric patients with recurrent patellar instability that failed conservative treatment were evaluated using computational reconstruction of in vivo patellofemoral function. Computational models were created from high-resolution MRI scans of the unloaded knee and lower-resolution scans during isometric knee extension at multiple flexion angles.

Management of the rigid cavus foot in children and adolescents.

This article reviews historical approaches to the various osteotomies in the treatment of rigid cavus feet in children, with an emphasis on the biplanar nature of historical osteotomies. The Akron dome midfoot osteotomy is performed at the apex of the rigid cavus deformity and allows for maximum correction in any plane, and for varus, valgus, dorsal, plantar, and rotational correction. In that regard, the Akron dome midfoot osteotomy provides the greatest amount of multiplanar correction.

A prospective comparison of computer-navigated and fluoroscopic-guided in situ fixation of slipped capital femoral epiphysis.

Background: Slipped capital femoral epiphysis (SCFE) is usually treated with percutaneous in situ screw fixation to prevent further progression of deformity. The purpose of this investigation is to compare computer navigation (CN) techniques with traditional fluoroscopic (fluoro) techniques for in situ fixation of SCFE.

Methods: This study was an IRB-approved prospective study of 39 hip pinnings in 33 children.

Limited benefit of hamstrings forces for the anterior cruciate ligament-deficient knee: an in vitro study.

The hamstrings are considered stabilizers of the anterior cruciate ligament-deficient knee; however, anterior cruciate ligament injury primarily influences tibiofemoral kinematics near full extension, where the hamstrings have the least influence on kinematics. Ten knees were tested at multiple flexion angles in vitro to directly compare the influence of anterior cruciate ligament injury and hamstrings activation on tibiofemoral kinematics. Tibiofemoral kinematics were measured for three testing conditions: (1) anterior cruciate ligament intact, with forces applied through the quadriceps muscles (596 N), (2) anterior cruciate ligament cut, with forces applied through the quadriceps, and (3) anterior cruciate ligament cut, with forces applied through the quadriceps and hamstrings (200 N).

All-epiphyseal ACL reconstruction improves tibiofemoral contact: an in vitro study.

Background: Anterior cruciate ligament (ACL) injury alters tibiofemoral contact during function, with a posterior shift of the point of contact on the tibia. An all-epiphyseal approach to ACL reconstruction is performed in pediatric patients to improve tibiofemoral contact without disturbing the physis. The hypothesis of the study is that all-epiphyseal ACL reconstruction will shift contact anteriorly on the tibia, as compared with the ACL-deficient knee.

Multiplanar supramalleolar osteotomy in the management of complex rigid foot deformities in children.

Purpose: Residual midfoot and hindfoot deformities in rigidly deformed feet present a very complicated surgical dilemma. A plantigrade foot is desirous for proper lower extremity mechanics in a child with ambulatory potential. In this group of patients, soft tissue procedures are no longer an appropriate option, and well-recognized hindfoot procedures, such as talectomy, have many disadvantages.

The incorporation of allogeneic and autogenous bone graft in healing of lateral column lengthening of the calcaneus.

Lateral column calcaneal lengthening as described by Mosca is a widely accepted technique for the correction of hindfoot valgus and pes planus. It is performed with both allogeneic and autogenous bone graft. The purpose of this study was to evaluate the incorporation of these 2 types of bone graft in this procedure.